|
FONDAPARINUX 2.5 MG/0.5 ML SUBCUTANEOUS SOLUTION SYRINGE [32215]
|
Facility
IP
|
$59.66
|
|
|
Service Code
|
CPT J1652
|
| Hospital Charge Code |
1722035
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.32 |
| Max. Negotiated Rate |
$50.71 |
| Rate for Payer: Blue Shield of California Commercial |
$42.48
|
| Rate for Payer: Blue Shield of California EPN |
$30.55
|
| Rate for Payer: Cash Price |
$26.85
|
| Rate for Payer: Cigna of CA HMO |
$41.76
|
| Rate for Payer: Cigna of CA PPO |
$41.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$23.86
|
| Rate for Payer: EPIC Health Plan Transplant |
$23.86
|
| Rate for Payer: Galaxy Health WC |
$50.71
|
| Rate for Payer: Global Benefits Group Commercial |
$35.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$39.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.32
|
| Rate for Payer: Multiplan Commercial |
$47.73
|
| Rate for Payer: Networks By Design Commercial |
$29.83
|
| Rate for Payer: Prime Health Services Commercial |
$50.71
|
|
|
FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE [108028]
|
Facility
OP
|
$108.64
|
|
|
Service Code
|
CPT J1652
|
| Hospital Charge Code |
1721167
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.96 |
| Max. Negotiated Rate |
$92.34 |
| Rate for Payer: Aetna of CA HMO/PPO |
$6.85
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6.85
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6.85
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$94.01
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$92.34
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$161.60
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$60.83
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$59.75
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$104.57
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$104.57
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$59.75
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$60.83
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$15.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$15.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$15.47
|
| Rate for Payer: BCBS Transplant Transplant |
$66.36
|
| Rate for Payer: BCBS Transplant Transplant |
$65.18
|
| Rate for Payer: BCBS Transplant Transplant |
$114.07
|
| Rate for Payer: Blue Shield of California Commercial |
$80.07
|
| Rate for Payer: Blue Shield of California Commercial |
$81.51
|
| Rate for Payer: Blue Shield of California Commercial |
$140.12
|
| Rate for Payer: Blue Shield of California EPN |
$5.96
|
| Rate for Payer: Blue Shield of California EPN |
$5.96
|
| Rate for Payer: Blue Shield of California EPN |
$5.96
|
| Rate for Payer: Cash Price |
$48.89
|
| Rate for Payer: Cash Price |
$49.77
|
| Rate for Payer: Cash Price |
$48.89
|
| Rate for Payer: Cash Price |
$49.77
|
| Rate for Payer: Cash Price |
$85.55
|
| Rate for Payer: Cash Price |
$85.55
|
| Rate for Payer: Cigna of CA HMO |
$76.05
|
| Rate for Payer: Cigna of CA HMO |
$77.42
|
| Rate for Payer: Cigna of CA HMO |
$133.08
|
| Rate for Payer: Cigna of CA PPO |
$76.05
|
| Rate for Payer: Cigna of CA PPO |
$77.42
|
| Rate for Payer: Cigna of CA PPO |
$133.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$161.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$92.34
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$94.01
|
| Rate for Payer: Dignity Health Media |
$94.01
|
| Rate for Payer: Dignity Health Media |
$161.60
|
| Rate for Payer: Dignity Health Media |
$92.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$92.34
|
| Rate for Payer: Dignity Health Medi-Cal |
$161.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$94.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$44.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$43.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$76.05
|
| Rate for Payer: EPIC Health Plan Transplant |
$76.05
|
| Rate for Payer: EPIC Health Plan Transplant |
$43.46
|
| Rate for Payer: EPIC Health Plan Transplant |
$44.24
|
| Rate for Payer: Galaxy Health WC |
$161.60
|
| Rate for Payer: Galaxy Health WC |
$92.34
|
| Rate for Payer: Galaxy Health WC |
$94.01
|
| Rate for Payer: Global Benefits Group Commercial |
$66.36
|
| Rate for Payer: Global Benefits Group Commercial |
$65.18
|
| Rate for Payer: Global Benefits Group Commercial |
$114.07
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$82.95
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$81.48
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$142.59
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$73.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$126.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$72.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$41.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$72.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$42.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$45.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.54
|
| Rate for Payer: Multiplan Commercial |
$152.10
|
| Rate for Payer: Multiplan Commercial |
$88.48
|
| Rate for Payer: Multiplan Commercial |
$86.91
|
| Rate for Payer: Networks By Design Commercial |
$55.30
|
| Rate for Payer: Networks By Design Commercial |
$54.32
|
| Rate for Payer: Networks By Design Commercial |
$95.06
|
| Rate for Payer: Prime Health Services Commercial |
$161.60
|
| Rate for Payer: Prime Health Services Commercial |
$94.01
|
| Rate for Payer: Prime Health Services Commercial |
$92.34
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$65.18
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$114.07
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$66.36
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$65.18
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$66.36
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$114.07
|
| Rate for Payer: United Healthcare All Other Commercial |
$95.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$55.30
|
| Rate for Payer: United Healthcare All Other Commercial |
$54.32
|
| Rate for Payer: United Healthcare All Other HMO |
$55.30
|
| Rate for Payer: United Healthcare All Other HMO |
$54.32
|
| Rate for Payer: United Healthcare All Other HMO |
$95.06
|
| Rate for Payer: United Healthcare HMO Rider |
$54.32
|
| Rate for Payer: United Healthcare HMO Rider |
$55.30
|
| Rate for Payer: United Healthcare HMO Rider |
$95.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$95.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$55.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$54.32
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$92.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$94.01
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$161.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$94.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$92.34
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$161.60
|
| Rate for Payer: Vantage Medical Group Senior |
$94.01
|
| Rate for Payer: Vantage Medical Group Senior |
$92.34
|
| Rate for Payer: Vantage Medical Group Senior |
$161.60
|
|
|
FONDAPARINUX 7.5 MG/0.6 ML SUBCUTANEOUS SOLUTION SYRINGE [108028]
|
Facility
IP
|
$110.60
|
|
|
Service Code
|
CPT J1652
|
| Hospital Charge Code |
1721167
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.54 |
| Max. Negotiated Rate |
$94.01 |
| Rate for Payer: Blue Shield of California Commercial |
$78.75
|
| Rate for Payer: Blue Shield of California Commercial |
$77.35
|
| Rate for Payer: Blue Shield of California Commercial |
$135.37
|
| Rate for Payer: Blue Shield of California EPN |
$97.34
|
| Rate for Payer: Blue Shield of California EPN |
$56.63
|
| Rate for Payer: Blue Shield of California EPN |
$55.62
|
| Rate for Payer: Cash Price |
$49.77
|
| Rate for Payer: Cash Price |
$48.89
|
| Rate for Payer: Cash Price |
$85.55
|
| Rate for Payer: Cigna of CA HMO |
$76.05
|
| Rate for Payer: Cigna of CA HMO |
$77.42
|
| Rate for Payer: Cigna of CA HMO |
$133.08
|
| Rate for Payer: Cigna of CA PPO |
$133.08
|
| Rate for Payer: Cigna of CA PPO |
$76.05
|
| Rate for Payer: Cigna of CA PPO |
$77.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$44.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$43.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$76.05
|
| Rate for Payer: EPIC Health Plan Transplant |
$76.05
|
| Rate for Payer: EPIC Health Plan Transplant |
$44.24
|
| Rate for Payer: EPIC Health Plan Transplant |
$43.46
|
| Rate for Payer: Galaxy Health WC |
$161.60
|
| Rate for Payer: Galaxy Health WC |
$94.01
|
| Rate for Payer: Galaxy Health WC |
$92.34
|
| Rate for Payer: Global Benefits Group Commercial |
$65.18
|
| Rate for Payer: Global Benefits Group Commercial |
$66.36
|
| Rate for Payer: Global Benefits Group Commercial |
$114.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$126.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$72.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$73.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$72.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$42.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$41.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$45.63
|
| Rate for Payer: Multiplan Commercial |
$86.91
|
| Rate for Payer: Multiplan Commercial |
$88.48
|
| Rate for Payer: Multiplan Commercial |
$152.10
|
| Rate for Payer: Networks By Design Commercial |
$54.32
|
| Rate for Payer: Networks By Design Commercial |
$55.30
|
| Rate for Payer: Networks By Design Commercial |
$95.06
|
| Rate for Payer: Prime Health Services Commercial |
$94.01
|
| Rate for Payer: Prime Health Services Commercial |
$92.34
|
| Rate for Payer: Prime Health Services Commercial |
$161.60
|
|
|
FOOT AND TOE PROCEDURES
|
Facility
IP
|
$18,603.60
|
|
|
Service Code
|
APR-DRG 3142
|
| Min. Negotiated Rate |
$14,270.92 |
| Max. Negotiated Rate |
$18,603.60 |
| Rate for Payer: IEHP Medi-Cal |
$14,270.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18,603.60
|
|
|
FOOT AND TOE PROCEDURES
|
Facility
IP
|
$44,772.78
|
|
|
Service Code
|
APR-DRG 3144
|
| Min. Negotiated Rate |
$34,345.43 |
| Max. Negotiated Rate |
$44,772.78 |
| Rate for Payer: IEHP Medi-Cal |
$34,345.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$44,772.78
|
|
|
FOOT AND TOE PROCEDURES
|
Facility
IP
|
$24,675.93
|
|
|
Service Code
|
APR-DRG 3143
|
| Min. Negotiated Rate |
$18,929.03 |
| Max. Negotiated Rate |
$24,675.93 |
| Rate for Payer: IEHP Medi-Cal |
$18,929.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$24,675.93
|
|
|
FOOT AND TOE PROCEDURES
|
Facility
IP
|
$17,475.67
|
|
|
Service Code
|
APR-DRG 3141
|
| Min. Negotiated Rate |
$13,405.68 |
| Max. Negotiated Rate |
$17,475.67 |
| Rate for Payer: IEHP Medi-Cal |
$13,405.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$17,475.67
|
|
|
FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION [88225]
|
Facility
IP
|
$11.15
|
|
|
Service Code
|
NDC 49502-605-30
|
| Hospital Charge Code |
NDG88225
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.68 |
| Max. Negotiated Rate |
$9.48 |
| Rate for Payer: Blue Shield of California Commercial |
$7.94
|
| Rate for Payer: Blue Shield of California EPN |
$5.71
|
| Rate for Payer: Cash Price |
$5.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.46
|
| Rate for Payer: Galaxy Health WC |
$9.48
|
| Rate for Payer: Global Benefits Group Commercial |
$6.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.68
|
| Rate for Payer: Multiplan Commercial |
$8.92
|
| Rate for Payer: Networks By Design Commercial |
$7.25
|
| Rate for Payer: Prime Health Services Commercial |
$9.48
|
|
|
FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION [88225]
|
Facility
OP
|
$11.15
|
|
|
Service Code
|
NDC 49502-605-30
|
| Hospital Charge Code |
NDG88225
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.68 |
| Max. Negotiated Rate |
$9.48 |
| Rate for Payer: Aetna of CA HMO/PPO |
$7.31
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.48
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.13
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.64
|
| Rate for Payer: BCBS Transplant Transplant |
$6.69
|
| Rate for Payer: Blue Shield of California Commercial |
$8.22
|
| Rate for Payer: Blue Shield of California EPN |
$6.51
|
| Rate for Payer: Cash Price |
$5.02
|
| Rate for Payer: Cash Price |
$5.02
|
| Rate for Payer: Cigna of CA HMO |
$7.14
|
| Rate for Payer: Cigna of CA PPO |
$8.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.48
|
| Rate for Payer: Dignity Health Media |
$9.48
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.46
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.46
|
| Rate for Payer: Galaxy Health WC |
$9.48
|
| Rate for Payer: Global Benefits Group Commercial |
$6.69
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$8.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.68
|
| Rate for Payer: Multiplan Commercial |
$8.92
|
| Rate for Payer: Networks By Design Commercial |
$7.25
|
| Rate for Payer: Prime Health Services Commercial |
$9.48
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.69
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.69
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.58
|
| Rate for Payer: United Healthcare All Other HMO |
$5.58
|
| Rate for Payer: United Healthcare HMO Rider |
$5.58
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.48
|
| Rate for Payer: Vantage Medical Group Senior |
$9.48
|
|
|
FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION [88225]
|
Facility
OP
|
$11.15
|
|
|
Service Code
|
NDC 49502-605-95
|
| Hospital Charge Code |
NDG88225
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.68 |
| Max. Negotiated Rate |
$9.48 |
| Rate for Payer: Dignity Health Medi-Cal |
$9.48
|
| Rate for Payer: Aetna of CA HMO/PPO |
$7.31
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.48
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.13
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$6.64
|
| Rate for Payer: BCBS Transplant Transplant |
$6.69
|
| Rate for Payer: Blue Shield of California Commercial |
$8.22
|
| Rate for Payer: Blue Shield of California EPN |
$6.51
|
| Rate for Payer: Cash Price |
$5.02
|
| Rate for Payer: Cash Price |
$5.02
|
| Rate for Payer: Cigna of CA HMO |
$7.14
|
| Rate for Payer: Cigna of CA PPO |
$8.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.48
|
| Rate for Payer: Dignity Health Media |
$9.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.46
|
| Rate for Payer: EPIC Health Plan Transplant |
$4.46
|
| Rate for Payer: Galaxy Health WC |
$9.48
|
| Rate for Payer: Global Benefits Group Commercial |
$6.69
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$8.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.68
|
| Rate for Payer: Multiplan Commercial |
$8.92
|
| Rate for Payer: Networks By Design Commercial |
$7.25
|
| Rate for Payer: Prime Health Services Commercial |
$9.48
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$6.69
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$6.69
|
| Rate for Payer: United Healthcare All Other Commercial |
$5.58
|
| Rate for Payer: United Healthcare All Other HMO |
$5.58
|
| Rate for Payer: United Healthcare HMO Rider |
$5.58
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$5.58
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.48
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.48
|
| Rate for Payer: Vantage Medical Group Senior |
$9.48
|
|
|
FORMOTEROL FUMARATE 20 MCG/2 ML SOLUTION FOR NEBULIZATION [88225]
|
Facility
IP
|
$11.15
|
|
|
Service Code
|
NDC 49502-605-95
|
| Hospital Charge Code |
NDG88225
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.68 |
| Max. Negotiated Rate |
$9.48 |
| Rate for Payer: Blue Shield of California Commercial |
$7.94
|
| Rate for Payer: Blue Shield of California EPN |
$5.71
|
| Rate for Payer: Cash Price |
$5.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.46
|
| Rate for Payer: Galaxy Health WC |
$9.48
|
| Rate for Payer: Global Benefits Group Commercial |
$6.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$7.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.68
|
| Rate for Payer: Multiplan Commercial |
$8.92
|
| Rate for Payer: Networks By Design Commercial |
$7.25
|
| Rate for Payer: Prime Health Services Commercial |
$9.48
|
|
|
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION [106783]
|
Facility
IP
|
$401.56
|
|
|
Service Code
|
NDC 0006-3061-01
|
| Hospital Charge Code |
1755762
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$96.37 |
| Max. Negotiated Rate |
$341.33 |
| Rate for Payer: Blue Shield of California Commercial |
$285.91
|
| Rate for Payer: Blue Shield of California EPN |
$205.60
|
| Rate for Payer: Cash Price |
$180.70
|
| Rate for Payer: Cigna of CA HMO |
$281.09
|
| Rate for Payer: Cigna of CA PPO |
$281.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$160.62
|
| Rate for Payer: EPIC Health Plan Transplant |
$160.62
|
| Rate for Payer: Galaxy Health WC |
$341.33
|
| Rate for Payer: Global Benefits Group Commercial |
$240.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$267.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$152.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$96.37
|
| Rate for Payer: Multiplan Commercial |
$321.25
|
| Rate for Payer: Networks By Design Commercial |
$200.78
|
| Rate for Payer: Prime Health Services Commercial |
$341.33
|
|
|
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION [106783]
|
Facility
IP
|
$42.00
|
|
|
Service Code
|
NDC 71839-104-01
|
| Hospital Charge Code |
1755762
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.08 |
| Max. Negotiated Rate |
$35.70 |
| Rate for Payer: Blue Shield of California Commercial |
$29.90
|
| Rate for Payer: Blue Shield of California EPN |
$21.50
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cigna of CA HMO |
$29.40
|
| Rate for Payer: Cigna of CA PPO |
$29.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$16.80
|
| Rate for Payer: Galaxy Health WC |
$35.70
|
| Rate for Payer: Global Benefits Group Commercial |
$25.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$28.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.08
|
| Rate for Payer: Multiplan Commercial |
$33.60
|
| Rate for Payer: Networks By Design Commercial |
$21.00
|
| Rate for Payer: Prime Health Services Commercial |
$35.70
|
|
|
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION [106783]
|
Facility
OP
|
$401.56
|
|
|
Service Code
|
NDC 0006-3061-01
|
| Hospital Charge Code |
1755762
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$96.37 |
| Max. Negotiated Rate |
$341.33 |
| Rate for Payer: Aetna of CA HMO/PPO |
$263.38
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$341.33
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$220.86
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$220.86
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$239.25
|
| Rate for Payer: BCBS Transplant Transplant |
$240.94
|
| Rate for Payer: Blue Shield of California Commercial |
$295.95
|
| Rate for Payer: Blue Shield of California EPN |
$234.51
|
| Rate for Payer: Cash Price |
$180.70
|
| Rate for Payer: Cash Price |
$180.70
|
| Rate for Payer: Cigna of CA HMO |
$281.09
|
| Rate for Payer: Cigna of CA PPO |
$281.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$341.33
|
| Rate for Payer: Dignity Health Media |
$341.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$341.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$160.62
|
| Rate for Payer: EPIC Health Plan Transplant |
$160.62
|
| Rate for Payer: Galaxy Health WC |
$341.33
|
| Rate for Payer: Global Benefits Group Commercial |
$240.94
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$301.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$267.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$152.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$96.37
|
| Rate for Payer: Multiplan Commercial |
$321.25
|
| Rate for Payer: Networks By Design Commercial |
$200.78
|
| Rate for Payer: Prime Health Services Commercial |
$341.33
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$240.94
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$240.94
|
| Rate for Payer: United Healthcare All Other Commercial |
$200.78
|
| Rate for Payer: United Healthcare All Other HMO |
$200.78
|
| Rate for Payer: United Healthcare HMO Rider |
$200.78
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$200.78
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$341.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$341.33
|
| Rate for Payer: Vantage Medical Group Senior |
$341.33
|
|
|
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION [106783]
|
Facility
OP
|
$42.00
|
|
|
Service Code
|
NDC 71839-104-01
|
| Hospital Charge Code |
1755762
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.08 |
| Max. Negotiated Rate |
$35.70 |
| Rate for Payer: Aetna of CA HMO/PPO |
$27.55
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$35.70
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$23.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$23.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$25.02
|
| Rate for Payer: BCBS Transplant Transplant |
$25.20
|
| Rate for Payer: Blue Shield of California Commercial |
$30.95
|
| Rate for Payer: Blue Shield of California EPN |
$24.53
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: Cigna of CA HMO |
$29.40
|
| Rate for Payer: Cigna of CA PPO |
$29.40
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$35.70
|
| Rate for Payer: Dignity Health Media |
$35.70
|
| Rate for Payer: Dignity Health Medi-Cal |
$35.70
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.80
|
| Rate for Payer: EPIC Health Plan Transplant |
$16.80
|
| Rate for Payer: Galaxy Health WC |
$35.70
|
| Rate for Payer: Global Benefits Group Commercial |
$25.20
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$31.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$28.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$16.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.08
|
| Rate for Payer: Multiplan Commercial |
$33.60
|
| Rate for Payer: Networks By Design Commercial |
$21.00
|
| Rate for Payer: Prime Health Services Commercial |
$35.70
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$25.20
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$25.20
|
| Rate for Payer: United Healthcare All Other Commercial |
$21.00
|
| Rate for Payer: United Healthcare All Other HMO |
$21.00
|
| Rate for Payer: United Healthcare HMO Rider |
$21.00
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$21.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$35.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$35.70
|
| Rate for Payer: Vantage Medical Group Senior |
$35.70
|
|
|
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION [106783]
|
Facility
OP
|
$401.56
|
|
|
Service Code
|
NDC 0006-3061-00
|
| Hospital Charge Code |
1755762
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$96.37 |
| Max. Negotiated Rate |
$341.33 |
| Rate for Payer: Aetna of CA HMO/PPO |
$263.38
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$341.33
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$220.86
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$220.86
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$239.25
|
| Rate for Payer: BCBS Transplant Transplant |
$240.94
|
| Rate for Payer: Blue Shield of California Commercial |
$295.95
|
| Rate for Payer: Blue Shield of California EPN |
$234.51
|
| Rate for Payer: Cash Price |
$180.70
|
| Rate for Payer: Cash Price |
$180.70
|
| Rate for Payer: Cigna of CA HMO |
$281.09
|
| Rate for Payer: Cigna of CA PPO |
$281.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$341.33
|
| Rate for Payer: Dignity Health Media |
$341.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$341.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$160.62
|
| Rate for Payer: EPIC Health Plan Transplant |
$160.62
|
| Rate for Payer: Galaxy Health WC |
$341.33
|
| Rate for Payer: Global Benefits Group Commercial |
$240.94
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$301.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$267.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$152.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$96.37
|
| Rate for Payer: Multiplan Commercial |
$321.25
|
| Rate for Payer: Networks By Design Commercial |
$200.78
|
| Rate for Payer: Prime Health Services Commercial |
$341.33
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$240.94
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$240.94
|
| Rate for Payer: United Healthcare All Other Commercial |
$200.78
|
| Rate for Payer: United Healthcare All Other HMO |
$200.78
|
| Rate for Payer: United Healthcare HMO Rider |
$200.78
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$200.78
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$341.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$341.33
|
| Rate for Payer: Vantage Medical Group Senior |
$341.33
|
|
|
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION [106783]
|
Facility
IP
|
$401.56
|
|
|
Service Code
|
NDC 0006-3061-00
|
| Hospital Charge Code |
1755762
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$96.37 |
| Max. Negotiated Rate |
$341.33 |
| Rate for Payer: Blue Shield of California Commercial |
$285.91
|
| Rate for Payer: Blue Shield of California EPN |
$205.60
|
| Rate for Payer: Cash Price |
$180.70
|
| Rate for Payer: Cigna of CA HMO |
$281.09
|
| Rate for Payer: Cigna of CA PPO |
$281.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$160.62
|
| Rate for Payer: EPIC Health Plan Transplant |
$160.62
|
| Rate for Payer: Galaxy Health WC |
$341.33
|
| Rate for Payer: Global Benefits Group Commercial |
$240.94
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$267.84
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$152.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$96.37
|
| Rate for Payer: Multiplan Commercial |
$321.25
|
| Rate for Payer: Networks By Design Commercial |
$200.78
|
| Rate for Payer: Prime Health Services Commercial |
$341.33
|
|
|
FOSCARNET 24 MG/ML INTRAVENOUS SOLUTION [10093]
|
Facility
IP
|
$2.27
|
|
|
Service Code
|
CPT J1455
|
| Hospital Charge Code |
1754909
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$1.93 |
| Rate for Payer: Blue Shield of California Commercial |
$1.62
|
| Rate for Payer: Blue Shield of California EPN |
$1.16
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: Cigna of CA HMO |
$1.59
|
| Rate for Payer: Cigna of CA PPO |
$1.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.91
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.91
|
| Rate for Payer: Galaxy Health WC |
$1.93
|
| Rate for Payer: Global Benefits Group Commercial |
$1.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Multiplan Commercial |
$1.82
|
| Rate for Payer: Networks By Design Commercial |
$1.14
|
| Rate for Payer: Prime Health Services Commercial |
$1.93
|
|
|
FOSCARNET 24 MG/ML INTRAVENOUS SOLUTION [10093]
|
Facility
OP
|
$2.27
|
|
|
Service Code
|
CPT J1455
|
| Hospital Charge Code |
1754909
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$488.71 |
| Rate for Payer: Aetna of CA HMO/PPO |
$488.71
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$74.21
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$65.31
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$65.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$144.51
|
| Rate for Payer: BCBS Transplant Transplant |
$1.36
|
| Rate for Payer: Blue Shield of California Commercial |
$1.67
|
| Rate for Payer: Blue Shield of California EPN |
$94.55
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: Cigna of CA HMO |
$1.59
|
| Rate for Payer: Cigna of CA PPO |
$1.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$89.05
|
| Rate for Payer: Dignity Health Media |
$59.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$65.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$80.15
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$59.37
|
| Rate for Payer: EPIC Health Plan Transplant |
$59.37
|
| Rate for Payer: Galaxy Health WC |
$1.93
|
| Rate for Payer: Global Benefits Group Commercial |
$1.36
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$97.37
|
| Rate for Payer: Heritage Provider Network Transplant |
$97.37
|
| Rate for Payer: IEHP Medi-Cal |
$96.18
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$96.18
|
| Rate for Payer: IEHP Medicare Advantage |
$59.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$140.33
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$59.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.54
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$74.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$79.55
|
| Rate for Payer: Multiplan Commercial |
$1.82
|
| Rate for Payer: Networks By Design Commercial |
$1.14
|
| Rate for Payer: Prime Health Services Commercial |
$1.93
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.36
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.36
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.14
|
| Rate for Payer: United Healthcare All Other HMO |
$1.14
|
| Rate for Payer: United Healthcare HMO Rider |
$1.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$89.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$65.31
|
| Rate for Payer: Vantage Medical Group Senior |
$59.37
|
|
|
FOSCARNET INTRAVITREAL INJECTION 2400 MCG/0.1 ML [4081568]
|
Facility
OP
|
$2.30
|
|
|
Service Code
|
CPT J1455
|
| Hospital Charge Code |
1754909
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$488.71 |
| Rate for Payer: Aetna of CA HMO/PPO |
$488.71
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$74.21
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$65.31
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$65.31
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$144.51
|
| Rate for Payer: BCBS Transplant Transplant |
$1.38
|
| Rate for Payer: Blue Shield of California Commercial |
$1.70
|
| Rate for Payer: Blue Shield of California EPN |
$94.55
|
| Rate for Payer: Cash Price |
$1.04
|
| Rate for Payer: Cash Price |
$1.04
|
| Rate for Payer: Cigna of CA HMO |
$1.61
|
| Rate for Payer: Cigna of CA PPO |
$1.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$89.05
|
| Rate for Payer: Dignity Health Media |
$59.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$65.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$80.15
|
| Rate for Payer: EPIC Health Plan Medicare/Senior |
$59.37
|
| Rate for Payer: EPIC Health Plan Transplant |
$59.37
|
| Rate for Payer: Galaxy Health WC |
$1.96
|
| Rate for Payer: Global Benefits Group Commercial |
$1.38
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$97.37
|
| Rate for Payer: Heritage Provider Network Transplant |
$97.37
|
| Rate for Payer: IEHP Medi-Cal |
$96.18
|
| Rate for Payer: IEHP Medi-Cal Transplant |
$96.18
|
| Rate for Payer: IEHP Medicare Advantage |
$59.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$140.33
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$59.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.55
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$74.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$79.55
|
| Rate for Payer: Multiplan Commercial |
$1.84
|
| Rate for Payer: Networks By Design Commercial |
$1.15
|
| Rate for Payer: Prime Health Services Commercial |
$1.96
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.38
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.38
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.15
|
| Rate for Payer: United Healthcare All Other HMO |
$1.15
|
| Rate for Payer: United Healthcare HMO Rider |
$1.15
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.15
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$89.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$65.31
|
| Rate for Payer: Vantage Medical Group Senior |
$59.37
|
|
|
FOSCARNET INTRAVITREAL INJECTION 2400 MCG/0.1 ML [4081568]
|
Facility
IP
|
$2.30
|
|
|
Service Code
|
CPT J1455
|
| Hospital Charge Code |
1754909
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$1.96 |
| Rate for Payer: Blue Shield of California Commercial |
$1.64
|
| Rate for Payer: Blue Shield of California EPN |
$1.18
|
| Rate for Payer: Cash Price |
$1.04
|
| Rate for Payer: Cigna of CA HMO |
$1.61
|
| Rate for Payer: Cigna of CA PPO |
$1.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.92
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.92
|
| Rate for Payer: Galaxy Health WC |
$1.96
|
| Rate for Payer: Global Benefits Group Commercial |
$1.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.55
|
| Rate for Payer: Multiplan Commercial |
$1.84
|
| Rate for Payer: Networks By Design Commercial |
$1.15
|
| Rate for Payer: Prime Health Services Commercial |
$1.96
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET [14825]
|
Facility
IP
|
$109.52
|
|
|
Service Code
|
NDC 0456-4300-08
|
| Hospital Charge Code |
ERX14825
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$26.28 |
| Max. Negotiated Rate |
$93.09 |
| Rate for Payer: Blue Shield of California Commercial |
$77.98
|
| Rate for Payer: Blue Shield of California EPN |
$56.07
|
| Rate for Payer: Cash Price |
$49.28
|
| Rate for Payer: Cigna of CA HMO |
$76.66
|
| Rate for Payer: Cigna of CA PPO |
$76.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$43.81
|
| Rate for Payer: Galaxy Health WC |
$93.09
|
| Rate for Payer: Global Benefits Group Commercial |
$65.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$73.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$41.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.28
|
| Rate for Payer: Multiplan Commercial |
$87.62
|
| Rate for Payer: Networks By Design Commercial |
$71.19
|
| Rate for Payer: Prime Health Services Commercial |
$93.09
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET [14825]
|
Facility
OP
|
$96.38
|
|
|
Service Code
|
NDC 70700-268-99
|
| Hospital Charge Code |
ERX14825
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$23.13 |
| Max. Negotiated Rate |
$81.92 |
| Rate for Payer: Aetna of CA HMO/PPO |
$63.22
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$81.92
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$53.01
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$53.01
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$57.42
|
| Rate for Payer: BCBS Transplant Transplant |
$57.83
|
| Rate for Payer: Blue Shield of California Commercial |
$71.03
|
| Rate for Payer: Blue Shield of California EPN |
$56.29
|
| Rate for Payer: Cash Price |
$43.37
|
| Rate for Payer: Cigna of CA HMO |
$67.47
|
| Rate for Payer: Cigna of CA PPO |
$67.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$81.92
|
| Rate for Payer: Dignity Health Media |
$81.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$81.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.55
|
| Rate for Payer: EPIC Health Plan Transplant |
$38.55
|
| Rate for Payer: Galaxy Health WC |
$81.92
|
| Rate for Payer: Global Benefits Group Commercial |
$57.83
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$72.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$64.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.13
|
| Rate for Payer: Multiplan Commercial |
$77.10
|
| Rate for Payer: Networks By Design Commercial |
$62.65
|
| Rate for Payer: Prime Health Services Commercial |
$81.92
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$57.83
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$57.83
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$57.83
|
| Rate for Payer: United Healthcare All Other Commercial |
$48.19
|
| Rate for Payer: United Healthcare All Other HMO |
$48.19
|
| Rate for Payer: United Healthcare HMO Rider |
$48.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$48.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$81.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$81.92
|
| Rate for Payer: Vantage Medical Group Senior |
$81.92
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET [14825]
|
Facility
IP
|
$83.76
|
|
|
Service Code
|
NDC 67877-749-57
|
| Hospital Charge Code |
ERX14825
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$20.10 |
| Max. Negotiated Rate |
$71.20 |
| Rate for Payer: Blue Shield of California Commercial |
$59.64
|
| Rate for Payer: Blue Shield of California EPN |
$42.89
|
| Rate for Payer: Cash Price |
$37.69
|
| Rate for Payer: Cigna of CA HMO |
$58.63
|
| Rate for Payer: Cigna of CA PPO |
$58.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$33.50
|
| Rate for Payer: Galaxy Health WC |
$71.20
|
| Rate for Payer: Global Benefits Group Commercial |
$50.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$55.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$31.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.10
|
| Rate for Payer: Multiplan Commercial |
$67.01
|
| Rate for Payer: Networks By Design Commercial |
$54.44
|
| Rate for Payer: Prime Health Services Commercial |
$71.20
|
|
|
FOSFOMYCIN TROMETHAMINE 3 GRAM ORAL PACKET [14825]
|
Facility
IP
|
$96.38
|
|
|
Service Code
|
NDC 70700-268-94
|
| Hospital Charge Code |
ERX14825
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$23.13 |
| Max. Negotiated Rate |
$81.92 |
| Rate for Payer: Blue Shield of California Commercial |
$68.62
|
| Rate for Payer: Blue Shield of California EPN |
$49.35
|
| Rate for Payer: Cash Price |
$43.37
|
| Rate for Payer: Cigna of CA HMO |
$67.47
|
| Rate for Payer: Cigna of CA PPO |
$67.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.55
|
| Rate for Payer: Galaxy Health WC |
$81.92
|
| Rate for Payer: Global Benefits Group Commercial |
$57.83
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$64.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$23.13
|
| Rate for Payer: Multiplan Commercial |
$77.10
|
| Rate for Payer: Networks By Design Commercial |
$62.65
|
| Rate for Payer: Prime Health Services Commercial |
$81.92
|
|
